Synopsis On 11 December 1993, the bulk carrier NIRJA, carrying a partial load of steel, was attempting to berth at a slip in Hamilton Harbour, Ontario. While turning off the entrance to the slip in strong stern winds and with three tugs assisting, the NIRJA did not successfully negotiate the turn and struck the tanker HAMILTON ENERGY which was moored alongside the oil barge PROVMAR TERMINAL I at the entrance to the slip. There was no injury or pollution, but the wharf and the vessels involved sustained some damage. The Board determined that the NIRJA, while manoeuvring in strong wind conditions under the conduct of a pilot, did not successfully negotiate the turn into the slip and struck the HAMILTON ENERGY because the vessel was not stopped in the available distance. The fact that the tugs were not secured to the vessel, that the anchor was not deployed and that the performance of the pilot was probably less than optimal contributed to the accident. 1.0 Factual Information 1.1 Particulars of the Vessels 1.1.1 Description of the Vessels The NIRJA is a conventional bulk carrier with bridge, accommodation and engine-room aft of the six cargo holds. The vessel is fitted with a bulbous bow. On the fore-and-aft centre line, there are three steel masts and six slewing derricks. The HAMILTON ENERGY is a small, single-hull tanker used for ship refuelling in the Great Lakes area. At the time of the occurrence, the vessel was double-banked starboard side to the PROVMAR TERMINALI on the north face of Pier 24. 1.2 Description of the Voyage Upon arrival at Hamilton on 07December 1993, the NIRJA anchored inside the harbour breakwater awaiting a berth. On 11December at 1100(3), a pilot boarded the NIRJA at anchor. Due to strong stern winds, the pilot, in consultation with the master, called for three tugs to assist in berthing the vessel. At 1220, the port anchor of the NIRJA was weighed and the vessel backed out of the anchorage. When her allocated berth became available, the NIRJA proceeded toward Pier23, the southernmost slip of the harbour. The pilot, who had the conduct of the vessel, the master, the officer of the watch (OOW) at the engine telegraph, and a quartermaster at the helm were on the bridge. Between 1230 and 1240, the three tugs rendezvoused with the NIRJA which was off Section 27 (see AppendixA), and were positioned on the port side of the bulk carrier abreast of hatches Nos.1, 3 and 6, respectively. The vessel was proceeding on the starboard side of the centre channel heading on to a chimney landmark beyond the channel. At 1235, the OOW noted the vessel's approximate position as being off the knuckle of Pier21. At 1249, when the vessel was off Section 26 and moving ahead at between three and four knots (kn) in a south-easterly direction, the main engine was stopped. The three tugs began assisting under the direction of the pilot. None was made fast to the NIRJA. At 1254, slow astern was ordered, followed about half a minute later by half astern. The tug abreast of hatch No.6 was ordered to push closer to the bow in way of hatch No.1 along with the other two tugs. When the bow reached the knuckle of Pier 23, the vessel barely began turning to starboard. At 1255, the engine telegraph was placed on full astern followed about half a minute later by emergency full astern. Subsequently, orders were given to let go the starboard anchor, but the anchor was not dropped. At 1258, the bow of the NIRJA came in contact with the HAMILTON ENERGY aft of the engine-room bulkhead. 1.3 Injuries to Persons No one was injured as a result of this occurrence. 1.4.1 Damage to the Wharf and Pollution The cement wall face of the wharf was cracked and broken over a length of 4m. There was no pollution. 1.4.2 Damage to the Vessels The NIRJA sustained indentation of the bulbous bow. The HAMILTON ENERGY sustained damage to four strakes of shell plating and associated internals on the port and starboard sides in way of the engine-room. Some auxiliary machinery and piping were also damaged. The supports to the boat deck on the starboard side were also buckled. The oil barge PROVMAR TERMINALI, moored between the HAMILTON ENERGY and the wharf, sustained damage in way of the poop deck area where the boarding ladder access platform was heavily buckled and fractured. The sheer strake plating was set in and the pump-room bulkheads, fore and aft, were buckled. 1.5 Certification 1.5.1 Vessel The NIRJA was certificated, equipped and manned in accordance with existing regulations. 1.5.2 Personnel The personnel on the bridge, in the engine-room and at forward stations held qualifications appropriate for the class of vessel on which they were serving and for the voyage beingundertaken. The tug masters were appropriately certificated. The pilot was appropriately licensed for this pilotage area. 1.6 Personnel History 1.6.1 Master The master had served in this capacity since 1984. He had been master of the NIRJA sinceApril 1992 and had made several trips to the Great Lakes. 1.6.2 Pilot The pilot had been with the Great Lakes Pilotage Authority since 1978. His responsibilities were primarily in the region of the Great Lakes and the St.Lawrence River District No.2 area above Cornwall, Ontario. He had piloted several vessels in and out of Hamilton Harbour in stronger wind conditions, and had piloted the NIRJA on several occasions in the past. 1.6.2.1 Pilot's Medical Requirements In accordance with existing regulations, the pilot had undergone his annual medical examination the previous year. Reportedly, he was not taking any medication at the time of the occurrence nor did he have any disability. 1.7 Weather Information The Burlington Bridge registered northerly winds at 22kn gusting to 28kn. According to the pilot, the wind as reported by the Burlington Bridge operator was northerly at 20 to 21mph (17 to 18kn). The tug masters and the vessel's complement reported that winds were north-westerly at 25kn, gusting to 30kn and that, at the time of the occurrence, the winds were gusting. 1.8 Navigation Equipment There was a full range of navigation equipment on board, adequate for the safe operation of the vessel. No equipment malfunction was reported and the appropriate navigation chart was in use at the time of the occurrence. 1.9 Main Engine Operation and Manoeuvring The main engine is operated from the control room located in the engine-room, and orders are transmitted from the bridge by telegraph. The telegraph is fitted with an audible alarm that rings until the telegraph orders have been acknowledged. The vessel is also fitted with bridge controls for the main engine, but the use of the system had been discontinued for some time. Astern power is generally 75percent of ahead power. The engine response times are as follows: - from stop to either ahead or astern propulsion: approximately 9 seconds; and - 25 to 35 seconds for the propeller to reach the maximum of 90rpm from stop. The pilot acknowledged that, while departing the anchorage, it had taken the engine nineseconds to respond. He did not complain about the main engine efficiency until after the astern movement had been ordered off the slip. He then complained that the requested astern power was not available. Several ahead and astern movements had been executed following the occurrence, and no problem was reported. According to the pilot, the maximum rpm astern attained during manoeuvring was 90rpm at both full astern and emergency full astern. According to the crew, the maximum rpm reached during emergency full astern was 95 to 96 as per the engine performance characteristics. 1.9.1 Engine-room Manning A change of engine-room watch personnel had taken place shortly before the occurrence. There were five engineering staff in the control room at the time of the occurrence: the chief engineer (at the main engine controls), the second engineer, the third engineer, the fourthengineer and the electrician. The chief engineer was carrying out the manoeuvring, the electrician was making entries in the engine-room movement book, and the three other engineers were standing by. 1.10 Vessel Manoeuvrability In the loaded condition, the vessel's speed at dead slow ahead and slow ahead is 4kn and 6kn, respectively, and in the ballast condition, her speed increases by 1kn. Steerageway can be maintained at a minimum speed of 4.2kn in the loaded condition and 4.6kn in the ballast condition. With the engine at slow ahead and a crash stop manoeuvre executed, the vessel will travel a distance of 1.4nautical miles(M) and take some 6minutes to come to a stop in the loaded condition, and 0.7M and 4minutes 40seconds, respectively, in the ballast condition (see AppendixB). 1.10.1 Visibility from the Bridge Neither the disposition of the masts nor the derricks interfered with the navigational visibility from the bridge. 1.11 Depth of Water and Vessel Draught The height of water was 0.59m above the International Great Lakes Datum 1955, and the depth of water as depicted on Canadian Hydrographic Service (CHS) chart No.2067 is 8.2m. The depth of water at the time of the occurrence was therefore 8.79m. The deepest reported draught of the vessel was 7.26m. Sounding checks carried out after the accident confirmed the charted water depths. 1.12 Deployment of Tugs Three tugs were used to assist the vessel in manoeuvring/berthing: None of the tugs was secured to the vessel because the pilot wanted the freedom to move the tugs along the length of the vessel as required and to avoid the tugs being caught between the NIRJA and any fixed structures in the area. 1.13 Communication 1.13.1 Pilot/Tug Communication The pilot communicated with the tugs by portable very high frequency (VHF) radiotelephone. Reportedly, no communication problem was experienced. 1.13.2 On-board Communication 1.13.2.1 Helm Orders and Execution Helm orders were given in English and, although not conversant in English, the helmsman had a complete understanding of helm orders. According to the pilot, when the vessel was headed on to a chimney, he ordered steady as she goes. The pilot indicated that the ship's head was going to starboard. Consequently, he ordered hard-a-port helm and dead slow ahead on the engine. Once the vessel was steadied, hard-a-port helm was maintained under the direction of the pilot, and the helm was ordered amidships when the engine was ordered astern. The pilot also indicated that execution of helm orders was not a factor in this occurrence. 1.13.2.2 Bridge/Forecastle Communication Communication between the chief officer positioned at the bow and the master on the bridge was by means of a portable radio. 1.14 Master/Pilot Exchange of Information The pilot was presented with the Pilot Card on boarding, and the exchange of information between the master and the pilot included the following: the ship's propeller was fixed-pitch and right-handed; astern propulsion would result in the bow going to starboard; astern propulsion was 75percent of ahead propulsion; and the engine response time was about nine seconds. The master discussed the securing of the tugs to the vessel with the pilot and suggested to the pilot the effectiveness of using the pier knuckle to swing the vessel into the slip under the prevailing wind conditions. However, the pilot felt it would be risky to secure the tugs or to make use of the unfendered knuckle. He indicated that he would carry out his normal approach of swinging the vessel directly into the slip without securing the tugs to the vessel. 1.15 Master/Pilot Rapport The rapport between the master and the pilot was reportedly good. According to the master, the pilot seemed confident; however, following the accident, he was a lot more careful. At no time did the master take over the conduct of the vessel from the pilot. As the pilot had in-depth local knowledge and as the tugs were under his control, the master allowed the pilot to continue having the conduct of the vessel. The master considered that taking over the conduct of the vessel from the pilot at a crucial stage in the manoeuvre would only have led to disruption and further compromised safety. 1.16 Vessel Speed/Engine Response The pilot maintained that, while en route to the slip, the master had commented that the vessel was proceeding slowly. However, the pilot explained to the master that he would be increasing the vessel's speed from dead slow ahead to slow ahead for an additional couple of minutes (the period in question being from 1240 to 1242). Furthermore, the pilot reportedly ordered full astern four times, then emergency full astern, and subsequently ordered to let go the anchor. Although he confirmed that the telegraph in the wheel-house had been set to full astern, the pilot reported that he had not received adequate astern power. It seemed to him that the NIRJA was like a dead ship and that there were no usual indicators of progressive astern power, such as vibration or black smoke from the funnel, which led him to believe that there was some operational delay in executing the engine manoeuvre. The pilot further indicated that the engine response time was about 10 seconds from stop to slow astern, and a further 15 to 20 seconds to attain 90 rpm astern. The deck movement book recorded the following sequence of engine movements: 1255.5: Double Ring (Emergency) Full Astern According to the pilot's recollection of events, following the recorded 1242 entry in the movement book, he ordered stop engine and steady as she goes. As the vessel's head did not steady, the pilot ordered dead slow ahead for a few moments and the helm hard-a-port before ordering stop engine. The ship's bridge personnel indicated that there was no abnormal delay in engine response. The master reportedly expressed his concerns to the pilot and maintained that he had considered the vessel's headway to be considerable for the stern wind conditions. His concerns went unaddressed and, by 1255, he deemed it necessary to countermand the pilot's order of Full Astern. He personally took over the telegraph from the OOW and rang Emergency Full Astern. He then reinforced the urgency by telephoning the control room and asking for maximum astern power. According to the engineering staff, there was no mechanical problem before, during or after the accident, and there was sufficient starting air for the main engine. All engine movements were promptly executed and the main engine responded appropriately. One of the tug masters indicated to the pilot that the NIRJA was rapidly closing with the HAMILTON ENERGY. From that tug, no propeller wash was observed until the vessel was within 60m (200feet) of the HAMILTON ENERGY. 1.17 Deployment of Anchor While the vessel was proceeding toward the berth, the boatswain was on the forecastle engaged in berthing preparations. When orders were given to let go the anchor, the chiefofficer was near the windlass and the boatswain was in the vicinity, but his precise position is not known. The chief officer ran forward and, after looking over the side, informed the bridge that the vessel was too close to the HAMILTON ENERGY and that it was unsafe to drop the anchor. There is conflicting evidence as to whether or not the master conveyed this information to the pilot. While the pilot maintained that the anchor was not ready to let go, the crew maintained that it was. The pilot based his conclusion on the fact that he did not see anyone move on the forecastle. He nonetheless also indicated that, in his preplanning for emergencies, he always ensures that the anchor is ready for immediate deployment. The vessel's planned manoeuvre did not call for the deployment of the starboard anchor or the use of the unfendered knuckle to negotiate the turn into the slip. 1.18 Reporting of Clearances The clearances between the vessel's bow and objects ahead were conveyed by the chiefofficer to the master. There is conflicting evidence as to whether or not the master relayed this information to the pilot. The pilot maintained that the tugs kept him apprised of the distances. He further commented that it is difficult to get ship personnel to keep him informed of the distances ahead. However, the pilot did not indicate having made such a request to the NIRJA. 1.19 Collective Agreement and Hours of Work Under the collective agreement between the Great Lakes Pilotage Authority and ThePilots'Corporation, Lake Ontario and Harbours, pilots in this region work 20 days then are off for 8 days. When on duty, the pilots must have a 12-hour rest period after each trans-lake assignment. Pilots may, during periods of heavy traffic, volunteer their services and take on additional assignments on their designated days off. According to the pilot, following a trans-lake assignment, the dispatcher may allocate another assignment if no other pilot is available. Pilots must ensure that they are well rested, able and willing to carry out the assignment, and decide whether or not to take on such additional assignments. The pilot indicated that he had taken on additional assignments because he was well rested. 1.19.1 Pilot's Scheduled Assignments The pilot commenced his tour of duty on 09December 1993 after eight days off. He had noassignment on that day. The following day, 10December, he boarded a vessel at PortWeller, Ontario, at approximately 1530 and piloted her to Cape Vincent, Lake Ontario, arriving there around midnight. He then boarded an upbound freighter at about 0230 on 11December and piloted her to Port Weller, arriving there at approximately 1030. He then went to the pilot office and was asked to take on another assignment in Hamilton. The ship'sagent drove him to Hamilton where he boarded the NIRJA at about 1100. The pilot maintained that, on each of the two trans-lake assignments, he had had about five hours'sleep and was consequently rested. He also indicated that he had had to get up at Mid-Lake Ontario calling-in point (CIP) to make a report to the Vessel Traffic Centre (VTC). The accident occurred at 1300 on 11 December, some 22 hours from the time of his first assignment. Following the NIRJA assignment, the pilot returned to the pilot station where he was asked to take on another (fourth) assignment which he declined. 1.20 Demand for Pilotage Services Near the end of the Seaway navigation season, there is a demand to move a large number of foreign vessels out of the system. The pilot, therefore, responded to the increased demand for pilotage services. 1.21 Pilotage Requirements To ensure safe and efficient navigation in Canadian waters where local knowledge is essential, compulsory pilotage areas have been established by the pilotage authorities and are defined in the Great Lakes Pilotage Regulations. Under the Pilotage Act, a licensed pilot who has the conduct of the ship is responsible to the master for the safe navigation of the ship. Should the master, who has the command of the vessel, feel that the safety of his vessel is compromised, he may take over the conduct of the vessel from the pilot. In such an eventuality, the master is required to file an official report with the pilotage authority. In this instance, the master did not take over the conduct of the vessel and no report was filed with the Great Lakes Pilotage Authority. 1.21.1 Decision to Depart Anchorage Neither the pilot nor the master had reservations respecting berthing of the vessel in the prevailing weather conditions. 1.22 Performance Degradation Factors Sleep loss and sleepiness resulting from extended duty or altered work/rest schedules have been identified as contributory factors in many industrial accidents(4). Research into circadian rhythms and sleep indicates that there are maximum sleepiness times and maximum wakefulness times during each 24-hour period. Under normal conditions, for most people, maximum sleepiness occurs between 0300 and 0500, and a second natural period of sleepiness occurs between 1500 and 1700. Similarly, there are maximum wakefulness periods when people find it difficult to sleep, and any sleep they do achieve at these times will not have the same restorative value. Research also suggests that it is not possible to store sleep. As a person remains awake, a sleep need develops, notwithstanding how well rested the individual was at the beginning of the wake cycle. The sleep need continues building until a person goes to sleep. On average, people need 7.5 to 8.5hours of sleep per day. A person obtaining less than his/her required sleep develops a sleep debt and will be subject to performance degradation. Performance on cognitive and vigilance tasks is particularly impaired and there is an increased propensity for risk-taking by fatigued persons. Cumulative sleep loss and circadian disruption can lead to decreased waking alertness, impaired performance, and worsened mood(5). Researchers at the Defence and Civil Institute of Environmental Medicine found that a30percent decrement in performance on cognitive tasks can be expected after 18 hours of wakefulness(6). Breaks or periods of low workload had no effect on performance levels. The only intervention which maintained or restored levels of performance was sleep. People are poor judges of their own levels of fatigue and alertness. Caffeine, physical activity, or interesting conversation can mask the effects of sleep debt and fatigue. It has been demonstrated that individuals (especially sleepy individuals) do not reliably estimate their alertness and performance(7). Sleep quality and duration are negatively affected by many factors, including use of stimulants, such as caffeine, time of day, light, and environment. People tend to experience poor sleep in surroundings different than their normal place of rest(8); (e.g. aboard a ship on a different mattress with a different noise level and tone, vibration, temperature, andhumidity). 1.22.1 Pilot Training and Safety The work environment of pilots requires them to work irregular schedules which are sometimes demanding and involve work in adverse weather conditions. The negative effects of shift work and irregular work schedules can, however, be mitigated by a combination of sleep schedules and control of one's environment and diet. Training and educational programs to help workers maintain optimum performance despite irregular work/rest schedules have been developed and can be customized to meet specific needs. Material is available on work-related stress, fatigue and performance maximization for people with irregular work schedules. However, the Great Lakes Pilotage Authority has neither a directive nor an educational program in place to provide guidance to pilots. 1.23 Operational Pressures - NIRJA Reportedly, there was no pressure from the owners or charterers to proceed to the slip and, during the master/pilot exchange of information, weather was not considered a factor preventing the vessel from berthing.